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WHA Improvement ForumFor August
“Establishing the Accountable Culture”
Jill Hanson & Stephanie Sobczak
Courtesy Reminders: •Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) •Please do not take calls and place the phone on HOLD during the presentation. 1
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Today’s Webinar
Agenda
The “two jobs” in healthcare Discovering root causes for the lack of accountability Strategies to “move” toward a culture of accountability.
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We all have two jobs
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1.The job we are hired to do
2.Improving the job we are hired to do
Because it just doesn’t work to have others
change the work we do.
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Institutionalize Accountability
Question: Can the QI department be totally accountable for clinical and patient outcomes?
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Answer is: Yes.IF your QI department places central lines,
administers medications, performs surgical procedures, removes caths, hangs IVs, applies falls/pressure ulcer/VTE interventions, etc.
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Clinical Areas & Accountability
• Clinical areas that “do the process” are naturally the only people who can effect the outcome.
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Unintended consequences If the roles become “murky”….• Quality is tasked with reporting and doing• Clinical areas are too far removed from their
measureable outcomes• Everything is a priority• Eyes are taken “off the ball” – something is missed• Capacity to be agile and adapt to change (i.e. new
evidence, rules and regs) is limited.
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“If you do it; you own it”
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1.Are the clinical areas looking at their outcome data?
2.Are both management and front-line care giving staff invested in the outcomes?
3.Are there ‘in process’ measures that help front-line staff see how their daily actions impact outcomes?
4.Are physicians invested in the outcomes and involved in the improvement?
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Identifying Root Causes
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Identifying When Improvement Stalls
You know it might be stalling when….1. Failure to launch – never gets off the ground.2. Gets “re-prioritized” soon after starting.3. No complaining, questioning or discussion about the
topic – it’s too quiet .4. Begin to notice “regression” - back to the old way.5. Your measures don’t move or decline.6. Team members run the other way when they see you!
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What You Might Hear
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I don’t have time to do this.
I can’t get anyone to help me
I don’t know what my role is
This is another ‘flavor of the month’
We already tried these things
We’re doing fine, why do we need to work on it?
I thought (____) was going to do that
Its not my job to work on improvement
My dog ate my PDSA form
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Are these the true issues, or is there an underlying reason?
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Typical Reasons1. Lack of clear accountability or lack of a process to
hold people accountable.2. Leaders don’t clearly emphasize the importance of the
improvement work during the day to day.3. Process to move forward isn’t followed (such as
PDSA).4. No one looks at the data, or measurement isn’t even
happening no way to see if the work makes sense.5. Missed opportunities for coaching or getting feedback
on how it’s going.12
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Key Root Cause Questions• What?
– Determine the issue: missing data, not meeting, no progress
• Who?– The person ultimately accountable for the project outcome – The leader to whom the team reports
• How?– Ask to see documentation (such as examples of small tests of
change) or data regularly
• When?– Regularly scheduled opportunity to share data/results AND– Just-in-time opportunities to ask
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Addressing AccountabilityTaking a Tight-Loose-Tight approach to managing can
help with issue of accountability
The origin is from management guru Tom Peters. He coined the term “Tight/Loose”
Later the other “Tight” was added which refers to accountability for the deliverables and/or outcome. (credited to Baldrige consultant Doug Sears)
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T-L-T DefinedTight – What has to be done? Who is accountable for
doing it? What the parameters and expectations are? When it should be completed?
Loose – How it is done and who gets to participate.
Tight – Timelines and deliverables are met; Progress is made and, if not, there are consequences.
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T-L-T Actions
• Tight – Model the importance of improving quality and safety; make clear who is accountable for leading improvement and actively participating in improvement initiatives. Make clear your expectations for knowing about the progress of the work. Be transparent about limitation – financial or otherwise.
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T-L-T Actions
• Loose – Give advice to teams; Model effective project management; Provide access to resources; Assist in addressing barriers to the work. Give the team the space to try new things.
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T-L-T Actions
• Tight – Informally, and frequently, ask for updates on progress; Solicit formal reports; Arrange presentations; Ensure access to key committees for formal reporting, sharing proposals and updates; Insist on seeing data
• Ensure there are consequences for not following-through
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What & Who? How? By When? What you will get:
Loose Loose Loose Chaos; the ‘tail wagging the dog’; ineffective, “loose-y goose-y” workplace.
Tight Tight Tight “Micro-managed” staff that seem like they won’t work independently; can’t get along with others; describe work as “walking on eggshells”.
Tight Tight Loose Staff work on projects and seem busy, but no real beneficial outcome occurs (i.e. projects that go on forever….)
Tight Loose Loose Poorly executed delegation, empowering staff handle the why, but forgetting the outcome
Tight Loose Tight Staff that know what is important, and what is expected – and get the job done.
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The Secret Formula
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Tight - Loose- Tight
Results!
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What Is Different In This Approach?• Makes improvement work more real-time & real • Less “management” led and more front-line led• Greater emphasis on measuring process• Quicker decision making about changes• Emphasis on spreading change and adopting
change in weeks (not months)• Focus on tracking improvement for sustaining
success
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The Tight-Loose-Tight Worksheet for Managers
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Tight – Loose – Tight Worksheet
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Using the Tool - Example
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Using the Tool - Example
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Using the Tool - Example
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Using the T-L-T Tool
• Review prior to meeting with the accountable person/s
• Use for self-coaching about T-L-T• Not meant to be a permanent tool to use, just
to help ‘hardwire’ your management practices around accountability.
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Institutionalizing Accountability
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Governance & Accountability
Quality and/or Practice councils:• Review the outcomes• Make decisions on what are the priorities• Communicate the priorities house wide• Marshall the resources to do the work
Refrain from “doing the work”• Hold clinical areas accountable for their outcomes.
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Managers Role in Accountability
• Ensure the department priorities align with those of the hospital
• Communicate the priorities to staff & discuss• Clearly define expectations ( ex: Is participating
in improvement a requirement of the job?)• Support with needed resources• Apply Tight – Loose – Tight management
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QI’s Role in Accountability • Provide a structured approach for improvement.• Provide access to the outcome results for the
clinical areas.• Provide assistance interpreting those results.• Advocate for the clinical areas needing assistance.• Assist with strategizing plans to take action.• Facilitate the process of improvement.
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Next Month: September 26
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Managing the Improvement “Portfolio”
SeptemberNoon
Methods for Sustaining great outcomes Monitoring Multiple Projects Taking Action when Action is Needed
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References• Quality Improvement Workbook Sections 1 and 5
• The Improvement Guide: A Practical Approachto Enhancing Organizational Performance, Langley,
Moen, & Nolan
• WHA Quality Center Tools and Templates http://www.whaqualitycenter.org/PartnersforPatients/PfPTools.aspx
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AnnouncementsPartners for Patients – Improvement Leader Fellowship (ILF):• Helps staff boost their QI knowledge to better execute their HEN projects
as well as future improvement work your organization may take on. • Beginning August 21st, two-hour webinar Fellowship sessions every two
weeks through the end of the year. These sessions will blend QI knowledge along with the content of the 10 HEN topics.
• Low-risk/low-investment to expose staff to this material without having to arrange travel, staff coverage, etc.
• Each session will provide CEU credits.
Questions/More Information – Contact Travis Dollak ([email protected]) or Tom Kaster ([email protected])
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Thank You!Questions
Please complete 3 question survey when closing webinar window.
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